Asian Pacific Journal of Tropical Biomedicine (2011)39-42 39
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Asian Pacific Journal of Tropical Biomedicine
Document heading doi:10.1016/S2221-1691(11)60065-8
Antibiotic sensitivity pattern of bacterial pathogens in the intensive care unit of
Fatmawati Hospital, Indonesia
Maksum Radji1*, Siti Fauziah1, Nurgani Aribinuko2
Laboratory of Microbiology and Biotechnology, Department of Pharmacy, Faculty of Mathematics and Science, University of Indonesia, Depok,
Department of Intensive Care Unit, Fatmawati Hospital, Jakarta, Indonesia
ARTICLE INFO ABSTRACT
Article history: Objective: To evaluate the sensitivity pattern of bacterial pathogens in the intensive care unit
Received 2 September 2010 (ICU) of a tertiary care of Fatmawati Hospital Jakarta Indonesia. Methods: A cross sectional
Received in revised form 27 September 2010 retrospective study of bacterial pathogen was carried out on a total of 722 patients that were
Accepted 15 Octorber 2010 admitted to the ICU of Fatmawati Hospital Jakarta Indonesia during January 2009 to March 2010.
Available online 1 February 2011 All bacteria were identified by standard microbiologic methods, and their antibiotic susceptibility
testing was performed using disk diffusion method. Results: Specimens were collected from
Keywords: 385 patients who were given antimicrobial treatment, of which 249 (64.68%) were cultured
Antibiotic susceptibility positive and 136 (35.32%) were negative. The most predominant isolate was Pseudomonas
Intensive care unit aeruginosa (P. aeruginosa) (26.5%) followed by Klebsiella pneumoniae (K. pneumoniae) (15.3%)
Bacterial resistance and Staphylococcus epidermidis (14.9%). P. aeruginosa isolates showed high rate of resistance
Bacterial pathogen to cephalexin (95.3%), cefotaxime (64.1%), and ceftriaxone (60.9%). Amikacin was the most
Sensitivity pattern effective (84.4%) antibiotic against P. aeruginosa followed by imipenem (81.2%), and meropenem
Antimicrobial (75.0%). K. pneumoniae showed resistance to cephalexin (86.5%), ceftriaxone (75.7%), ceftazidime
Resistance (73.0%), cefpirome (73.0%) and cefotaxime (67.9%), respectively. Conclusions: Most bacteria
Pseudomonas aeruginosa isolated from ICU of Fatmawati Hospital Jakarta Indonesia were resistant to the third generation
Klebsiella pneumoniae of cephalosporins, and quinolone antibiotics. Regular surveillance of antibiotic susceptibility
Isolate patterns is very important for setting orders to guide the clinician in choosing empirical or
Specimen directed therapy of infected patients.
rates of infection, especially infections due to resistant
1. Introduction Staphylococci, Acinetobacter, Pseudomonas species,
and Candida species. Moreover, the ICU mortality of
Antibiotic resistance is a major world-wide problem in the infected patients was more than twice that of non-infected
intensive care unit (ICU), including in Indonesia. It has been patients. Most ICU patients that acquired infections are
realized that the spread of drug resistant organisms in the associated with the use of invasive devices such as catheters
ICU is related to the widespread use of antibiotics. The rate and mechanical ventilators.
of antimicrobial resistance in the ICU is several folds higher Globally, patients in the ICU have encountered an
than in the general hospital setting. Many surveillance increasing emergence and spread of antibiotic-resistant
efforts have drawn attention to this phenomenon[1-4]. pathogens. The worldwide incidence rate is 23.7 infections
ICU is one of potential sources of nosocomial infections per 1 000 patient days. Rates of nosocomial infections
even in countries where extensive infection control range from 5 % to 30 % among ICU patients. Although
measures are routinely implemented. The international ICUs generally comprise < 5% of all hospital beds, they
study of infection in ICU which was conducted in 2007, and account for 20% to 25% of all nosocomial infections. The
involved with 1 265 ICUs from 75 countries, demonstrated increased risk of infection is associated with the severity of
that patients who had longer ICU stays had higher the patient’s illness, length of exposure to invasive devices
and procedures, increased patient contact with healthcare
*Corresponding author: Dr. Maksum Radji, M Biomed, Laboratory of Microbiology personnel and length of stay in the ICU.
and Biotechnology, Department of Pharmacy, Faculty of Mathematics and Sciences In Indonesia, there have been few studies of antibiotic
University of Indonesia, Depok, 16424, Indonesia.
Tel: 62-21-78849002 use, especially in ICU setting. Therefore, the objective of
Fax: 62-21-7863433 this study was to determine the antibiotic sensitivity pattern
40 Maksum Radji et al./Asian Pacific Journal of Tropical Biomedicine (2011)39-42
of bacteria isolated from patients in the ICU of Fatmawati Enterobacter aerogenes (E. aerogenes) (13.3%), Klebsiella
Hospital, Jakarta, Indonesia. ozaenae (K. ozaenae) (8.4%), Escherichia coli (E. coli) (5.2%),
Serratia liquifaciens (S. liquifaciens), respectively, as shown
in Table 1. In this study almost bacteria isolated from ICU
2. Materials and methods of Fatmawati Hospital Jakarta Indonesia were resistant to
cephalexin (75%-95%) as shown in Table 2.
A cross-sectional study was carried out based on reports
of bacteria isolates from the ICU of Fatmawati Hospital, Table 1
from January 2009 to March 2010. The Fatmawati Hospital The frequency of microorganisms isolated from patients admitted in
ICU of Fatmawati Hospital [n (%)].
is a tertiary care and teaching hospital with 740 beds, which
was located in Jakarta, Indonesia. During this period, 722 No Microorganism Frequency
patients were admitted to the ICU, and 385 of them received 1 P. aeruginosa 66 (26.5)
antimicrobial treatment. All samples that were collected 2 K. pneumoniae 38 (15.3)
aseptically from the 385 patients were plated right after the 3 S. epidermidis 37 (14.9)
collection. Identification of all causative microorganisms 4 E. aerogenes 32 (13.3)
was performed by standard microbiologic methods. 5 K. ozaenae 21 (8.4)
Susceptibility testing was performed using disk diffusion 6 E. coli 13 (5.2)
method. The results were interpreted according to the 7 S. liquifaciens 10 (4.0)
guidelines of the Clinical and Laboratory Standards Institute 8 Staphylococcus aureus 8 (3.2)
(CLSI). 9 Klebsiella spp. 5 (2.0)
10 Serratia marcessens 4 (1.6)
11 Pseudomonas fluorescens 3 (1.2)
3. Results 12 Enterobacter cloacae 2 (0.8)
13 Enterobacter spp. 2 (0.8)
During January 2009 to March 2010, 249 (64.68%) of the 14 Streptococcus group A 1 (0.4)
385 specimens, were culture positive and 136 ( 35.32%) 15 Pseudomonas putida 1 (0.4)
specimens showed no growth. The most common locations 16 Acinetobacter baumannii 1 (0.4)
for infection were respiratory tract (78.7%), urinary tract 17 Klebsiella terrigena 1 (0.4)
(7.6%), surgical site (7.5%), blood (3.8%), and peritoneal 18 Proteous mirabilis 1 (0.4)
fluid (2.4%). Pseudomonas aeruginosa (P. aeruginosa) was 19 Raoutella ornithinolytica 1 (0.4)
the most frequently isolated bacteria (26.5%), followed 20 Burkholderia cepacia 1 (0.4)
by Klebsiella pneumoniae (K. pneumoniae) ( 15.3 %), Total 249 (100.0)
Staphylococcus epidermidis (S. epidermidis) ( 14.9 %),
Antibiotic resistance pattern of predominant microorganisms isolated from patients admitted in ICU of Fatmawati Hospital (%).
Antibiotic P. aeruginosa K. pneumoniae S. epidermidis E. aerogenes K. ozaenae E. coli S. liquifaciens
(n=66) (n=38) (n=37) (n=32) (n=21) (n=13) (n=10)
Cephalexin 95.3 86.5 75.0 83.9 95.2 76.9 90.0
Ceftazidime 42.2 73.0 72.2 58.1 85.7 38.5 30.0
Ceftriaxone 60.9 75.7 64.9 61.3 85.7 46.2 70.0
Cefotaxime 64.1 67.9 67.9 67.7 100.0 46.2 50.0
Cefepime 35.9 56.8 54.1 38.7 61.9 38.5 30.0
Cefpirome 59.4 73.0 56.8 67.7 81.9 38.5 50.0
Imipenem 18.8 5.4 18.9 3.2 9.5 0.0 20.0
Meropenem 25.0 5.4 32.4 3.2 9.5 7.7 10.0
Amikasin 15.6 10.8 0.0 3.2 9.5 15.4 20.0
Gentamicin 39.1 59.5 0.0 61.3 76.2 38.5 40.0
Ciprofloxacin 56.3 64.9 63.9 51.6 85.7 46.2 60.0
Ofloxacin 53.1 62.2 58.3 48.4 76.2 46.2 70.0
Moxifloxacin 50.0 62.2 38.9 45.2 76.2 30.8 60.0
Levofloxacin 42.2 62.2 50.0 41.9 6.2 53.8 60.0
Fosfomycin 28.1 2.7 29.7 12.9 23.8 7.7 0.0
Indonesia . Another study showed the most frequent
4. Discussion bacteria isolated in Dr. Kariadi Hospital, Semarang
Indonesia were P. aeruginosa (50.9%), E. aerogenes (37.5%)
This result revealed that P. aeruginosa, Klebsiella spp., and E. coli (8.7%). P. aeruginosa demonstrated multidrug
and E. coli were still predominant isolates as previously resistance to several antibiotics.
investigated in ICU of Fatmawati Hospital Jakarta, A very high rate of resistance (>72%) was observed among
Maksum Radji et al./Asian Pacific Journal of Tropical Biomedicine (2011)39-42
S. epidermidis and Klebsiella spp isolates to ceftazidime, from ICU samples were P. aeruginosa, Klebsiella spp. and
whereas E. coli, S. epidermidis, E. aerogenes, P. aeruginosa, Staphylococcus aureus.
Klebsiella spp. and Serratia spp., resistant to ceftriaxone. In Canada, the Canadian National Intensive Care
P. aeruginosa isolates showed high rate of resistance to Unit study conducted during 2005-2006, showed that P.
cephalexin (95.3%), cefotaxime (64.1%), and ceftriaxone aeruginosa, Staphylococcus aureus, Haemophilus influenzae,
(60.9%). Amikacin was the most effective (84.4%) antibiotic Enterococcus spp., Staphylococcus pneumoniae, and K.
against P. aeruginosa followed by imipenem (81.2%), and pneumoniae are the most common isolates recovered
meropenem (75.0%). from clinical specimens in Canadian ICU s. Moreover,
We found that K. pneumoniae was also multidrug P. aeruginosa is the most frequent multi drug-resistant
resistant bacteria to the third generation cephalosporins, phenotype, which is resistance to three or more of the
and quinolone antibiotics. K. pneumoniae showed high rate antibiotics including cefepime, piperacillin-tazobactam,
of resistance to cephalexin (86.5%), ceftriaxone (75.7%), meropenem, amikacin or gentamicin, and ciprofloxacin.
ceftazidime (73.0%), cefpirome (73.0%) and cefotaxime In Indonesia, beside P. aeruginosa, another multi
(67.9%). Similar observations to our study demonstrated drug resistant E. coli was also found as pathogen of
that 96%-100% K. pneumoniae and P. aeruginosa isolated nosocomial infection, furthermore these E. coli isolates
from ICU patients were resistant to ceftazidime[10,11]. K. were high rates of resistance to ampicillin, ciprofloxacin,
pneumoniae isolates were also resistant to ciprofloxacin chloramphenicol, and trimethoprim-sulphamethoxazole.
( 64.9 %), ofloxacin ( 62.2 %), moxifloxacin ( 62.2 %), and The prescribing of antibiotics in the ICU is usually
levofloxacin (62.2%). This finding is related most probably empiric. Therefore, the ongoing surveillance of antibiotic
due to the extensive usage of third generation cephalosporins susceptibility patterns of predominant bacteria is a
and quinolone antibiotics at the ICU of Fatmawati Hospital. fundamental effort to monitor changes in susceptibility
Another interesting result of this study is fosfomycin showed patterns and to guide the clinician in choosing empirical
good sensitivity against all bacteria isolated from ICU or directed therapy appropriately, especially in ICU setting.
admitted patients, most probably because this antibiotic Appropriate antibiotic utilization in ICU is crucial not only
is not commonly used in our setting. The sensitivity of in ensuring an optimal outcome, but also in preventing the
fosfomycin was better than imipenem and meropenem. emergence of multi drug resistance bacteria.
Antibiotic use contributes to the emergence of
antimicrobial resistance in gram positive as well as gram
negative bacteria[2,12,13]. In developing countries, antibiotics Conflict of interest statement
are prescribed for 44%-97% of patients in hospital, often
inappropriately[14,15]. In Indonesia, a high proportion (84%) We declare that we have no conflict of interest.
of patients in hospital received an antibiotic but 32% of
prescription is an inappropriate indication.
In Asian countries including Indonesia, the most Acknowledgements
frequent pathogen isolated from infections in the ICU
are P. aeruginosa, Klebsiella spp., E. coli, Enterococcus, We would like to acknowledge The Fatmawati Hospital
and Staphylococcus aureus. For example, in 12 ICUs in Jakarta, for research collaboration between Department of
seven Indian cities, overall 87.5% of all Staphylococcus Pharmacy, University of Indonesia and Fatmawati Hospital
aureus health care associated infections were caused by Jakarta, Indonesia.
methicillin-resistant strains, 71.4% of Enterobacteriaceae
were resistant to ceftriaxone and 26.1% to piperacillin-
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